Patient Product Needs: *Patient Product Needs:Incontinence for my childCatheters for womenCatheters for menOstomyCGM & Diabetic SuppliesParent/Guardian Name *Child's First Name (Patient) *Child's Last Name (Patient) *Email Address *Phone Number *What state do you live in? *What state do you live in?AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingEnter your eligible state: *Enter your eligible state:AlabamaGeorgiaKentuckyMarylandMississippiOhioPennsylvaniaIf your state is not listed, we are currently working on becoming in-network providers. Please stay tuned for updates.Are you insulin dependent? *YesNoPatient Date of Birth *Patient Date of Birth (AL) *Eligible for ages 3-20 yrsPatient Date of Birth (GA) *Eligible for ages 2-20 yrsPatient Date of Birth *Incontinence for children in MS, KY, MD, NY, OH, PA from 3+Insurance Provider InformationAmerigroupCareSourceMedicaidMedicareThird-Party InsuranceNoneEnter your insurance (if other is selected) *Preferred Method of Contact: *CallTextEmailBest time of day to contact you? *MorningMid-DayAfternoonHow did you hear about us? *How did you hear about us?Word of MouthFacebook AdFacebook PostFriend/FamilyGoogle SearchInstagramClinician ReferralInsurance ReferralEmailConsent Age Requirements *You acknowledge that to qualify, the patient must be between the ages of 2-21 in GA, 3-20 in AL, and 3+ in MS, KY, MD, NY, OH, and PA, and must have been seen by a physician within the last 6 months.By clicking on the button below, I agree that UroStat Healthcare may contact me regarding healthcare products and services via email, text and telephone using automated technology at the telephone number(s) provided above. I realize this consent is not required to make a purchase.Send RequestPlease do not fill in this field.
